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Cleveland Care And Rehab Center

900 N Division St, Cleveland, OK 74020 · For profit - Limited Liability company · 90 certified beds · (918) 358-3135 Medicare & Medicaid certified

Call the home — (918) 358-3135 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Apr 2024Resident-funds citations (F0567, F0568, F0570)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,069 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0567, F0568, F0570)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,069 in federal fines (most recent 2025-03-19)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
119 S Broadway St · (918) 358-2501 · Call to confirm hours
Pharmacy
301 N Broadway St · (918) 358-2524 · Call to confirm hours
Grocery
501 N Broadway St · (918) 358-2774 · Call to confirm hours
Park
N Phillips Rd · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.7%13.6%15.4%better
Long-stay residents who lose too much weight1.8%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms15.3%3.4%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.8%4.7%3.3%better
Long-stay residents whose ability to walk worsened1.5%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.6%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine95.2%94.6%95.3%typical
Long-stay residents with pressure ulcers11.6%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control6.8%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.1%17.5%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine83.3%74.1%79.4%typical
Short-stay residents rehospitalized after admission30.1%27.3%22.6%worse
Short-stay residents with an outpatient ER visit0.0%16.6%12.0%check this — see note marked star below the table
Long-stay hospitalizations per 1,000 resident days2.692.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.872.961.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

11.6%U.S. median 10.7%
Went back to hospital
30.0%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 30.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 6.7–19.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge30.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge15.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge15.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.661.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.46
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.26
RN hoursweekends
72.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 90 beds and averages 61.3 residents a day — about 68% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.80 on weekdays — 13% thinner on weekends. RN hours go from 0.41 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-12-08)
7
at the previous standard inspection (2024-04-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2025-04-04 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 04/03/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide a safe and orderly discharge for Resident #7. Resident #7 was discharged to a prepaid motel room located away from their community, leaving the resident without identification, financial means, or caregiver support. The facility did not provide the resident with a 30-day notice of intent to discharge, nor notify the Office of the Ombudsman or the State agency (OSDH) of the resident's anticipated discharge as required. Resident #7 was a direct admitted from the Department of Corrections to the facility on [DATE] with Medicaid pending for their pay source status and without state issued identification, birth certificate, or social security card. Resident #7 was discharged from the facility on 02/26/25 to a motel room in Tulsa without financial means, identification, or caregiver/community support. The resident returned from the community based motel to the facility on [DATE]. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-12-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure medication was administered as ordered by the physician for 1 (#44) of 1 resident sampled reviewed for medication administration. The regional director identified 58 residents resided in the facility. Findings:A physician order, dated 07/09/24, showed Nystatin Powder was to be applied to folds, abdomen, and neck topically every shift. A significant change assessment, dated 11/17/25, showed Resident #44 had diagnosis which included candidiasis of the skin and nails. The assessment showed Resident #44 had a BIMS of 15 and was cognitively intact for daily decision making.A review of the November 2025 medication administration record for the night shift, showed Resident #44 had not received Nystatin Powder on November 10, 11, 12, 13, 14, 17, 18, 19, 20, 21, 25, 26, 27 and 28.On 12/08/25 at 10:14 a.m., the ADON stated if the check box on the medication administration record was not checked the task had been completed then they assumed it was not done.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to evaluate a resident for vaping/e-cigarette use safely for 1 (#44) of 2 sampled residents reviewed for safe smoking. The regional director identified 58 residents resided in the facility. Findings: On 12/02/25 at 2:53 p.m., Resident #44 was observed in bed wearing oxygen with a nasal canula attached to an oxygen concentrator. There were three pink vape-e-cigarettes smoking devices observed on the resident's bedside table. On 12/04/25 at 11:02 a.m., Resident #44 was observed in bed wearing oxygen with a nasal canula attached to an oxygen concentrator. There were three pink vape-e-cigarettes smoking devices observed on the resident's bedside table. A facility policy titled Smoking Protocol, dated 10/25/22, did not show vaping/e-cigarettes was addressed in the policy to prevent accidents and hazards. Resident #44's Smoking Safety Evaluation, dated 11/05/25, showed the resident did not smoke. Resident #44's comprehensive assessment, dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-08 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the head of bed was elevated for 1 (#5) of 1 resident reviewed for continuous tube feeding. The ADON identified two residents received tube feeding. Findings: On 12/03/25 at 8:43 a.m., Resident #5 was observed to receive continuous tube feeding without the head of their bed elevated. On 12/04/25 at 8:51 a.m., the head of bed for Resident #5 was observed to be flat and without elevation.On 12/04/25 at 12:25 p.m., the head of bed for Resident #5 was observed to be flat and without elevation. On 12/08/25 at 11:00 a.m., the head of bed for Resident #5 was observed to be flat and without elevation.A care plan, dated 08/08/25, showed Resident #5 had diagnoses which included severe protein calorie malnutrition and gastro-esophageal reflux disease.A significant change assessment, dated 11/21/25, showed Resident #5 had moderate cognitive impairment with a BIMS of 10.On 12/08/25 at 11:00 a.m., LPN #1 stated they had worked at the facility for one week and had not observed the head of Resident #5's bed to be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's nebulizer and oxygen mask were bagged when not in use to prevent cross contamination for 1 (#4) of 16 sampled residents reviewed for infection control practices. The regional director identified 58 residents resided in the facility. Findings: On 12/03/25 at 2:47 p.m., Resident #4 was not in their room. Resident #4's nasal cannula was observed laying bedside in a recliner loose and not in a bag. Resident #4 nebulizers mask was bedside with a hose attached laying on a cart under the window and not in a bag. Resident #4's physician orders, dated 01/10/25, showed Resident #4 had orders for albuterol sulfate inhalation solution 2.5 milligrams/3 milliliter orally via a nebulizer. Resident #4's physician orders, dated 07/04/25, showed Resident #4 had orders for continuous oxygen at two liters via an oxygen concentrator. The orders showed to store tubing and mask in a dry protective cover when not in use. Resident #4's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident with an allergy to latex did not receive an indwelling latex urinary catheter for 1 (#1) of 1 sampled resident reviewed for a latex allergy.The administrator identified 54 residents resided in the facility. The DON identified one resident with a latex allergy.Findings:An Allergy tab, dated 03/05/25, showed Res #1 had an allergy to latex.A physician order, dated 03/08/25, showed to maintain an indwelling silicone urinary catheter and to change monthly on the 6th of each month.An admission assessment, dated 03/12/25, showed Res #1 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #1 had an indwelling urinary catheter.A care plan, dated 03/18/25, showed Res #1 was allergic to latex. The care plan showed Res #1 would not receive medications and/or substances known to cause allergic reactions.A treatment administration record, dated 04/06/25, showed Res #1 had a new indwelling urinary catheter placed.A progress note, dated 04/09/25, showed Res #1's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide a resident with a bed wide enough to allow the resident to reposition themselves and side rails/trapeze bar for the resident to use in positioning for 1 (#2) of 3 residents sampled for accommodation of needs. The alphabetical resident roster identified 56 residents resided in the facility. Findings: On 03/28/25 at 11:45 a.m., Resident #2 was observed in bed with the head of the bed up approximately 45 degrees. The resident was on an air mattress with approximately 4 inches from their hip to the edge of the air mattress on either side. There were no side rails or a trapeze bar present. A facility policy titled Quality of Life - Accommodation of Needs, dated 02/01/16, read in part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being .The resident's individual needs and preferences shall be accommodated to the extent…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-19 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident and/or resident's representative the right to participate in the development and implementation of their person-centered plan of care for 1 (#5) of 1 sampled resident reviewed for care plan meetings. The DON identified 52 residents resided in the facility. Findings: A Comprehensive Person-Centered Care Plan policy, dated 01/23/19, read in part, 3. The Interdisciplinary Team, along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life history, preferences, and goals. 6. The Comprehensive Person Centered Care Plan can be revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessments per the RAI manual. Resident #5 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and kidney failure. Resident #5's clinical record was reviewed July 2024 through March 2025. There was no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-05 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents on antipsychotic medications were assessed for tardive dyskinesia for three (#6, 18, and #19) of five residents who were reviewed for unnecessary medications. The DON identified eight residents who were ordered antipsychotic medications. Findings: The Monitoring of Anti-Psychotics policy, dated 2024, read in parts, .Upon initiation of antipsychotic medication therapy [or upon admission for new residents receiving anti-psychotics] and every three months thereafter, the Abnormal Involuntary Movement Scale [AIMS] or similar test is administered to the resident. The results, and actions taken in response to the results, are recorded in the residents medical record . 1. Resident #6 had diagnoses which included Schizoaffective disorder, Bipolar type. An AIMS assessment, dated 01/09/23, was completed in the electronic clinical record. Review of the clinical record did not reveal any AIMS assessments after 01/09/23. The annual assessment, dated 01/20/24, documented the resident was moderately impaired cognitively…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-05 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 30 opportunities were observed with two errors. The total medication error rate was 6.67%. The DON identified 47 residents received medications in the facility. Findings: 1. Resident #14 had diagnoses which included rib fractures. The Physician's Orders, dated 02/02/24, documented Calcium 600mg by mouth daily for rib fracture. 2. Resident #32 had diagnoses which included cough and seasonal allergies. The Physician's Orders, dated 04/02/24, documented Geri-Tussin DM 10-100mg/5ml - give 10ml orally every four hours as needed for cough. On 04/03/24 at 8:48 a.m., CMA #1 was observed to administer Calcium 600mg plus vitamin D3 20mcg one tablet by mouth to Resident #14. On 04/03/24 at 3:23 p.m., CMA #2 was observed to administer 5ml of Geri-Tussin DM 10-100mg/5ml to Resident #32. On 04/04/24 at 9:51 a.m., CMA #1 stated they had not noticed the Calcium 600mg they had administered to Resident #14 included 20mcg of vitamin D3 and they should have…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure medications were dated when opened for three (300/400 hall medication cart, 200 hall treatment cart, and 400 hall treatment cart) of three medication/treatment carts observed. The DON identified five medication/treatment carts in the facility. Findings: 1. On 04/04/24 at 9:10 a.m., the 300/400 medication cart was observed with CMA #1. CMA #1 stated they were to date medications when they were opened. The following medications were observed to be open but not dated: a. Ketorolac eye drops for Resident #12. b. Imodium liquid 1mg/7.5ml house stock. c. Chloraseptic throat lozenges for Resident #22. On 04/04/24 at 9:11 a.m., the 200 hall treatment cart was observed with the ADON. The following medications were observed to be open but not dated: d. Breo Ellipta inhaler and icy hot cream for Resident #18. e. Levalbuterol nebulizer vials and nystatin cream for Resident #32. f. Anora inhaler for Resident #17. g. Spiriva inhaler for Resident #28. On 04/04/24 at 9:19 a.m., the 400 hall treatment cart was observed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Ecited before2024-04-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to implement a program designed to help prevent the development of Legionellosis. The administrator reported the census was 47. Findings: An undated facility policy titled Legionella Water Management Program, read in part, .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . The water management program includes the following elements . A detailed description and diagram of the water system . On 04/03/24 at 10:30 a.m., the maintenance director stated they did not have a detailed description and diagram of the water system.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to implement their abuse policy for one of five new employees reviewed for background checks. The Abuse Prevention policy, dated 10/21/2022 read in parts, . The facility will pre-screen all potential new employees and residents for a history of abusive behavior. A review of five new employees revealed one CNA #1 with no documented background check completed or in progress. On 04/03/24 at 03:47 p.m. the administrator stated they could not find a clearance letter for CNA#1. That apparently they never went to be fingerprinted. The CNA has been suspended and will not be allowed to work until final clearance has been received.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47. Findings: An Influenza Vaccine policy, dated 04/28/22, read in part, .The opportunity to receive the influenza vaccine will be extended to all residents and employees. The facility will provide the pertinent information regarding the risks/ benefits of receiving the influenza vaccine .An individual is not required to receive the influenza vaccine .resident refusal will be documented . Resident #41 had diagnoses including dementia and hypertension. A review of resident #41's immunization records did not document the resident had received or been offered a flu vaccination. On 04/04/23 at 11:59 a.m., the DON stated there was no additional documentation for Resident #41 regarding immunizations.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure COVID-19 vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47. Findings: An COVID Vaccine policy, revised 08/01/23, read in part, . The facility will offer the COVID Vaccine to employees/residents to assist in mitigating the spread of COVID-19 .COVID-19 Vaccinations will be offered to all residents/employees . Resident #41 had diagnoses including dementia and hypertension. A review of resident #41's immunization records did not document the resident had received or been offered a COVID-19 vaccination. On 04/04/23 at 11:59 a.m., the DON stated there was no additional documentation for Resident #41 regarding immunizations.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-06 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to employ a registered nurse as the full-time Director of Nursing. The DON identified 52 residents residing in the facility. Findings: On 12/04/23 at 12:33p.m., the DON stated they were a licensed practical nurse. On 12/04/23 at 2:05 p.m., the office placard which announced the office of the Director of Nursing was labeled with the name of the DON. On 12/06/23 at 12:20 p.m., the DON stated they signed their contract to accept the DON position on 09/14/23 and started on 09/18/23. The DON stated they employed registered nurses for at least eight hours every day in a supervisory position. On 12/06/23 at 12:25 p.m., the administrator stated they were aware of the regulation which required a registered nurse be employed in the position of DON.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to maintain personal funds in an interest-bearing account for all residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility. Findings: On 01/25/23 at 1:30 p.m., no documentation of residents on the trust fund having had their personal funds maintained in an interest-bearing account could be found with record review. On 01/25/23 at 1:50 p.m., the BOM was asked if residents on the trust fund had their personal funds maintained in an interest-bearing account. She stated the facility had not maintained the residents' personal funds in an interest-bearing account since March 2022. She stated the facility had not noticed the discrepancy until a few days ago. She stated the administrator had recently contacted the bank to correct the problem but it had not been corrected yet. On 01/25/23 at 1:59 p.m., the administrator stated the facility had not maintained the residents' trust fund in an interest-bearing account since March 2022. She stated the facility had not noticed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide quarterly financial statements to residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility. Findings: On 01/25/23 at 1:30 p.m., no documentation of receipt of quarterly financial statements by residents on the trust fund could be found with record review. On 01/25/23 at 1:48 p.m., the BOM was asked if residents on the trust fund were provided with quarterly financial statements. She stated financial statements were only provided upon request and not routinely on a quarterly basis. She stated she was not aware the financial statements were to be provided quarterly. On 01/25/23 at 1:56 p.m., the administrator stated financial statements had not been provided quarterly to residents on the trust fund since the facility changed ownership in November of 2021, but they should have been provided.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to obtain a surety bond to assure the security of all personal funds of residents. The administrator stated there are 18 residents on the trust fund in the facility. Findings: No documentation that the facility maintained a surety bond could be found upon record review. On 01/25/23 at 1:31 p.m., the BOM was asked if the facility had a surety bond to assure the security of all residents' personal funds. The BOM stated not being sure whether or not the facility had a surety bond. She stated the administrator should be questioned on the subject because she was not familiar with surety bonds. On 01/25/23 at 2:00 p.m., the administrator and corporate nurse #2 were asked for documentation that the facility maintained a surety bond to assure the security of all residents' personal funds. On 01/25/23 at 2:28 p.m., the corporate nurse #2 stated the facility had not obtained a surety bond since the facility changed ownership in November of 2021.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure MDS assessments were completed within the required time of the ARD for 13 (#5, 7, 11, 21, 34, 41, 98, 99, 100, 101, 102, 103, and #105) of 55 residents whose MDS dates were reviewed. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, documented admission assessments must be completed no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days), and quarterly assessments must be completed no later than 14 days after the ARD. 1. Res #5 had a documented admission date of 11/24/21. A quarterly MDS, with an ARD of 11/02/22, was documented as in progress as of 01/24/23. 2. Res #7 had a documented admission date of 02/07/22. A quarterly MDS, with an ARD of 11/20/22, was documented as in progress as of 01/24/23. 3. Res #11 had a documented admission date of 11/24/21. A quarterly MDS, with an ARD of 11/01/22, was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure MDS assessments were submitted and accepted by CMS no later than 14 calendar days after completion. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. Findings: A batch transmittal report, dated 10/08/22, documented two MDS assessments submitted later than 14 days after completion. A batch transmittal report, dated 10/28/22, documented one MDS assessment submitted later than 14 days after completion. A batch transmittal report, dated 10/31/22, documented eight MDS assessments submitted later than 14 days after completion. A batch transmittal report, dated 11/06/22, documented 11 MDS assessments submitted later than 14 days after completion. A batch transmittal report, dated 11/30/22, documented three MDS assessments submitted later than 14 days after completion. A batch transmittal report, dated 12/11/22, documented 11 MDS assessments submitted later than 14 days after completion. A batch transmittal report, dated 12/23/22, documented three MDS assessments submitted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of MDS assessments for two (#15 and #22) of three residents reviewed for MDS discrepancies. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. Findings: 1. Resident #15 had diagnoses which included congestive heart failure, myocardial infarction, and hypertension. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, documented in part .N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here . A physician order, dated 08/02/22, documented to administer Ticagrelor (an anti-platelet) tablet 90 mg twice daily. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-26 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure behavior and side effect monitoring for psychotropic medications was completed each shift for two (#30 and #35) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 42 residents received psychotropic medications. Findings: 1. Res #30 had diagnoses which included delusional disorders, major depressive disorder, and generalized anxiety disorder. A quarterly MDS, dated [DATE], documented the resident was cognitively impaired, had hallucinations, had physical behaviors one to three days, had verbal behaviors one to three days, had other behaviors one to three days, had rejection of care one to three days, received antipsychotic medications five of seven days. A physician order, dated 12/23/22, documented to administer Vraylar Capsule 1.5 mg one time a day. A physician order, dated 01/20/23, documented to administer Vraylar Capsule 3 mg one time a day. A monthly behavior monitoring…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM met the state requirement for DM. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. No residents were identified as receiving nutrition and hydration solely through tube feeding. Findings: There was no documentation the DM was certified as a dietary manager. On 1/25/22 at 10:10 a.m., the administrator provided a food handlers license, dated 05/12/21, for the DM. She stated the DM did not have a certification. She stated she had allowed the certification to lapse.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to perform hand hygiene prior to and after finger stick blood sugar monitoring and insulin administration. The Resident Census and Conditions of Residents report documented 12 residents received injections in the facility. Findings: On 01/25/23 at 11:27 a.m., LPN #1 was observed to have performed a FSBS and to have administered an insulin injection on Res #36. LPN #1 did not perform hand hygiene after removing gloves post procedure and prior to donning clean gloves. LPN #1 was then observed to have performed a FSBS and to have administered an insulin injection on Res #32. On 01/25/23 11:32 a.m., LPN #1 was observed to have performed a FSBS and to have administered an insulin injection on Res #24. LPN #1 did not perform hand hygiene after removing gloves post procedure and prior to donning clean gloves. LPN#1 was then observed to have performed a FSBS and to have administered an insulin injection on Res #102. On 01/25/23 at 11:56 a.m., LPN #1 was informed of the observation of lack of hand hygiene after removing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's code status was listed in the EHR for one (#21) of two residents sampled for advance directives. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. Findings: Res #21 had diagnoses which included Alzheimer's disease with late onset, hypertension, chronic kidney disease, diabetes, history of skin cancer, history of breast cancer, and history of pulmonary embolism. An admission assessment, dated [DATE], documented the resident was severely cognitively impaired and was receiving hospice services upon admission. On [DATE] at 3:00 p.m., Res #21's EHR was reviewed and did not document a code status for the resident. On [DATE] at 3:05 p.m., LPN #2 was asked what Res #21's code status was. She was unable to determine the resident's code status from the EHR or the paper chart. The LPN stated if the resident were to experience cardiac or respiratory arrest, the staff would start CPR and alert…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide the ABN form CMS-10055 and NOMNC form CMS 10123 to residents who received skilled services and afterwards stayed in the facility for two (#17 and #24) of three residents sampled for beneficiary protection notification review. The DON identified six residents who had discharged from skilled services in the last six months. Findings: According to Res #17's medical record, Res #17 started skilled services on 10/09/22 and was discharged on 11/18/22. The ABN and NOMNC forms were not provided. According to Res #24's medical record, Res #24 started skilled services on 10/14/22 and was discharged on 10/27/22. The ABN and NOMNC forms were not provided. On 01/25/23 at 3:14 p.m., the Administrator stated they are unable to find the NOMNC and ABN forms.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a baseline care plan for one (#21) of 14 residents whose care plans were reviewed. The administrator identified one resident who admitted in the last 30 days. Findings: Resident #21 had diagnoses which included Alzheimer's disease, hypertension, chronic kidney disease, diabetes, and anxiety. Res #21 was admitted to the facility on [DATE]. An admission MDS, dated [DATE], documented Res #21 was cognitively impaired; independent with walking, eating, locomotion, transfers, and bed mobility; supervision with eating, toilet use, and personal hygiene; limited assistance with dressing; extensive assistance with bathing; was occasionally incontinent of bowel and bladder; and was receiving hospice services. A Baseline Care Plan documented an initiated date of 01/25/23. On 01/26/23 at 8:38 a.m., the MDS coordinator stated the initial care plan was not done timely. She stated when she started in her position, two weeks ago, she was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to administer medication as ordered for one (#20) of six residents sampled for medication administration. The Resident Census and Conditions of Resident report documented 55 residents resided in the facility. Findings: Res #20 had diagnoses which included hypertension, peripheral vascular disease, major depressive disorder, and pain. A physician order, dated 05/04/22, documented to administer ibuprofen 200 mg three times daily for pain. On 01/26/23 at 7:55 a.m., administration of routine morning medications by CMA #1 was observed for Res #20. The resident did not receive Ibuprofen 200 mg by mouth as ordered at 8:00 a.m. on 01/26/23. CMA #1 stated the facility had run out of ibuprofen for this resident after the morning scheduled dose on 01/25/23. She stated Res #20 had not received three scheduled doses of this medication because the pharmacy had not delivered the ibuprofen yet. The January 2023 MAR documented Res #20 received ibuprofen on every scheduled dose except the 8:00 a.m. dose on 01/26/23. On 01/26/23…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a physician rationale was documented related to a declination of a GDR for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 55 residents resided in the facility. Findings: Res #30 had diagnoses which included delusional disorders, major depressive disorder, and generalized anxiety disorder. A physician order, dated 05/26/22, documented to administer sertraline 50 mg one time per day for anxiety. A medication regimen review, dated 06/30/22, documented a request to reduce Res #30's sertraline. The physician documented they disagreed with the request but did not document a rationale for their decision. A quarterly MDS, dated [DATE], documented the resident received antidepressant medications seven out of seven days of the review period. On 01/26/23 at 12:32 p.m., Corp RN #1 stated there was supposed to be a rationale for a declined GDR. She stated she would check the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. Findings: On 01/24/23 at 9:10 a.m., an initial brief tour of kitchen was conducted. On 01/24/23 at 9:12 a.m., a three-door refrigerator was observed containing a large pitcher of red liquid, dated 01/06/23; salad in a plastic storage container, dated 01/22/23; soup in plastic storage bowl, dated 01/22/23; and a tray with six plastic glasses of juice covered with clear wrap, dated 01/22/23. On 01/24/23 at 9:15 a.m., the DM was observed removing the salad and soup from the refrigerator and placing them by the dishwasher. She stated the refrigerators should be cleaned out every morning but it had not been done yet. She stated leftovers should only to be kept for 24 hours. On 01/24/23 at 9:17 a.m., a three compartment sink near the clean side of the dishwasher was observed. On the left side of the three compartment sink a large metal basin pan was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,069 in federal fines across 1 penalty.

  • $14,069 — penalty dated 2025-03-19

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MGM HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.3+1.7 vs chain
Health inspection 4 of 52.4+1.6 vs chain
Staffing 2 of 51.7+0.3 vs chain
Quality measures 3 of 53.6-0.6 vs chain
The other 26 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Arbor Hills Care & Rehab CenterFerguson, MO 1 of 5Bentwood Nursing & RehabFlorissant, MO 1 of 5Broadway Care & Rehab CenterMuskogee, OK 1 of 5Florissant Valley Health & Rehabilitation CenterFlorissant, MO 1 of 5Lansdowne VillageSaint Louis, MO 1 of 5Leisure Village Health Care CenterTulsa, OK 1 of 5Normandy Nursing CenterSaint Louis, MO 1 of 5Quarters At Des Peres, TheDes Peres, MO 1 of 5South Pointe Rehabilitation and Care CenterOklahoma City, OK 1 of 5Springfield Skilled Care CenterSpringfield, MO 1 of 5St Sophia Health & Rehabilitation CenterFlorissant, MO 2 of 5Eastgate Village Care & Rehab CenterMuskogee, OK 2 of 5Heritage Villa Care & Rehab CenterBartlesville, OK 2 of 5Sherbrooke VillageSaint Louis, MO 2 of 5Spring Valley Health & Rehabilitation CenterSpringfield, MO 2 of 5Sunset Health Care CenterUnion, MO 2 of 5Walnut Grove Care & Rehab CenterMcAlester, OK 3 of 5Forest Hills Care And Rehabilitation CenterBroken Arrow, OK 3 of 5Fort Gibson Care & Rehab CenterFort Gibson, OK 3 of 5Oak Park Care CenterSaint Louis, MO 4 of 5Coweta Care & Rehab CenterCoweta, OK 4 of 5Jackson ManorJackson, MO 4 of 5Mitchell Care & Rehab CenterMcAlester, OK 4 of 5Rainbow Health Care Community And Rainbow AssistedBristow, OK 4 of 5Seminole Care And Rehabilitation CenterSeminole, OK 5 of 5Camelot Nursing And Rehabilitation CenterFarmington, MO

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
OK SNF HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/09/2024
OK SNF INVESTMENTS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/09/2024
JFB OK TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 01/09/2024
SOUTHEAST VENTURES TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST48%since 01/09/2024
UPSHAW, BILLIEIndividualW-2 MANAGING EMPLOYEEsince 01/09/2024
FRIEDMAN, NAFTALIIndividualCORPORATE OFFICERsince 01/09/2024

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.4M
Net patient revenuemost recent cost report
-12.4%
Operating marginrevenue minus expenses
$688K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 9%Other / private 6%

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $688K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$262per resident / day
operating cost
$7,970per month
≈ monthly operating cost
$233per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375443. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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